Tuesday, June 16, 2009

The AMA, Going Reagan, Turns to Bean-Counting Again

It’s a “there you go again” moment for the American Medical Association.

We learn from CNN’s Elizabeth Cohen’s twitter pagethat the biggest standing ovation given to Obama by the AMA House of Delegates was in response to this line:

“You did not enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers – and that’s what our health care system should let you be.” (Here is the entire text of the president's speech.)

It is ironic that this sentiment in particular moved the AMA so, considering that the organization’s actions at the meeting so far indicate that bean counting—that is, counting their hard-earned money—is exactly why these doctors entered the profession.

First, they announced that they would not support an optional public insurance plan, because it might mean less money for doctors (though they appear now to be trying to recant that statement). They are basing their opposition on figures showing that Medicare pays doctors 20% less than private health plans, and therefore an expanded Medicare-like public insurance program might mean less money in their bank accounts.

A pay cut? Outrageous!

Here’s a news flash: all the players in the health care industry—doctors, hospitals, and insurance companies—are going to have to accept pay cuts if we want to bring health care spending under control. The AMA’s posture of knee-jerk opposition to anything that smacks of financial sacrifice gives it the look and feel of a reactionary organization, which is how they looked when they hired Ronald Reagan for "operation coffee cup" in its ill-fated effort to defeat Medicare in 1965.

Second, the AMA, yet again, has decided that its own ethics committee just doesn't understand medical ethics, at least when it comes to the topic of industry funding of continuing medical education. This is an issue I have covered here and here. One year ago, the first time the AMA read CEJA's report on CME (CEJA being the Council on Ethical and Judicial Affairs), the delegates rejected it because it announced the bad financial news that industry funding of education for doctors represents an unresolvable conflict of interest and therefore has to go.

Now, a year later, a new CEJA, under a new chair, introduced a new report, this time saying that industry funding of CME can continue, but it is still “ethically preferable” for doctors to pay for their own education. Apparently even this watered down version of medical ethics is unacceptable to the AMA, because defining industry-free CME as "preferable" might slow down the flow of industry cash, so they rejected it, referring it back to CEJA for more extreme dilutions. You can read the particulars on the Policy and Medicine blog.

Presumably, the next report will not dare to even mention ethics and industry funding in the same breath. I predict that the entire report will be brief and to the point: “Industry funding of CME is necessary for the public health.” Now that’s the kind of sentiment any bean-counting doctor can get behind!

12 comments:

Great post. As a young psychiatrist, I don't have the perspective that most older physicians do, but I have seen the profit motive infiltrate every aspect of my career.

I did not enter medicine to become rich. I assumed I would make a comfortable salary, but my primary motivation was the intellectual stimulation, patient contact, and sense of doing good for others. Unfortunately, throughout medical school (where most of my classmates competed aggressively for high-paying specialties) and residency (after which most of my classmates set out to open private practices in tony suburbs with no intention of accepting insurance-- let alone Medicare or Medicaid), I was surrounded by those who were clearly looking to make money first, treat illness second.

Right now I work in a community psychopharmacology clinic in an urban area in California, where most of my patients are indigent and uninsured. Here, too, however, some of my colleagues feel that the way to keep their incomes high is to provide hurried, substandard care (notes? what's a note?) that unfortunately does little to help patients (and don't even get me started on the quantity of benzos, stimulants, and antipsychotics we’re unnecessarily spilling onto our streets as a result). Of course, we're also constantly visited by drug reps who encourage us to use their meds without any understanding of the psychosocial stressors our patients are under. Everybody’s trying to make a buck, and we’re doing little to improve public health—at great long-term expense.

I would gladly accept a smaller income in order to provide more appropriate care-- care which would in many cases be non-psychiatric, but which would also be more personally rewarding and potentially more intellectually satisfying. I want to take the time to teach patients (or other doctors) about therapeutic approaches that are safer or more cost-effective. Unfortunately, in today's practice of medicine I'm rewarded instead for doing quick med checks where I prescribe expensive, potent meds, I'm not reimbursed for interventions that would enhance lifestyle, and the only way for me to educate other physicians or patients on a large-scale is to team up with some commercial outfit (funded by big pharma, of course) where intellectual curiosity is squelched.

Clearly, the AMA is not looking out for my interests. The question is, who does?

At the risk of being hypocritical, because I am grateful and appreciative to read there are others who, while the more often silent minority of us as physicians, feel as I do, I will forward a reply at this site after saying I was done commenting here. To stevebMD, don't give up your attitudes and beliefs, as I strongly believe I am one like you, albeit probably older, and I would hope wiser but also more jaded and cynical than I hope you will ever become. For just one voice of tens of thousands in our field, you are on the money for what you write here, and I think Dr Carlat would echo my comments, but I also think he has immersed himself in the politics of our field too visibly to risk too much to say what I have and will say again now.

Our colleagues, psychiatrists, especially the older ones who have been practicing for more than 25 years, have sold out and are in it only for themselves until proven otherwise. I respect they are probably angry and worn out fighting battles we as the younger generation of colleagues need to step up and battle more vigorously, but they as a whole have done us a great injustice as a profession, not just sold us out, but deemed us meaningless.

For what it is worth, the APA, the AMA, and most other established physician groups of size and substance do not speak for those who embrace the Hippocratic Oath and believe in principles like "first do no harm", and "go from least to most invasive". If you believe in these principles, don't stop, and speak out as forcefully and responsibly as you can. I appreciate what you have written here and Dr Carlat has posted. All I can say is thanks for being bold and honest. I wish I could, but I have been screwed so many times by colleagues for fighting back, I can't risk using my name any more.

Sincerely and appreciatively,

Skillsnotpills

ps: if there ever was an appropriate word verification during my responding here, angst as the word wins hands down!

I went to look at the policy blog and noticed a sentence about "the levels of ethics" and then later the observation "In the near future CME funding will come from many more diverse sources including the government. To say that one source of CME funding is more ethical than another is perhaps a decision better left to the physicians own judgment."

But there _are_ judgements to be made about funding sources. Didn't people get upset when it turned out some research on cancer diagnostics had been funded by the tobacco industry? Wouldn't it be unethical for an MD to select a mode of treatment based on what a family member paid them to choose for their elderly relative?

Real health care reform is going to knock the money out of many specialties. That's completely appropriate. People will have to choose these jobs based on what the real market can bear, and what specialties are really needed, not what industry glamour allows.

But whether real reform is possible when everyone wants to protect the part of the status quo that currently benefits _them_.....? I'm still waiting for any of these organizations to take a stand that puts the patients' needs ahead of their personal or corporate bank accounts.

You CAN and SHOULD teach other doctors about approaches that are safer and cost-effective.

What's to stop you from giving up an evening or two a month to give talks at a local medical society meeting, a local NAMI meeting, a medical staff meeting at a nearby hospital...

If not you, who?

You don't need to be attached to a big money pharm to do it.

I hope that not getting paid for this is what's stopping you.

Light a tiny fire somewhere. If everyone who felt the way that you do made sure that their own tiny corner of the world was covered, we'd be able to start to effect change.

And just for the record, you may be getting paid to do quick med checks, but I don't believe you are getting paid to prescribe expensive meds. The most effective and vetted meds in the psychotropic arsenal can be had in abundance for a song.

But that was back in the day, before drug addicts and borderlines all became "bipolar".

Your comments and the article are not accurate representations of what transpired at the AMA meeting with regard to the industry funding of CME CEJA report. Nor do you comment about the CEJA reports on Access and Quality that passed the House of Delegates. The AMA has changed, is changing, is a democratic organization (for good and ill!) so JOIN and ADVOCATE for patients.

I know this isn't a discussion forum, and I also realize that Steveb's stated motivations are admirable.

But I must point out something that strikes at the heart of what bothered me so much about the recent APA conference offerings: "Intellectual satisfaction," as Steve puts it, seems viewed as the polar opposite of psychopharmacology. As if the two cannot co-exist. As if being a good psychopharmacologist and giving medically treated disorders their due is somehow being intellectually lazy or "taking the easy way out."

Or, as one psychiatrist told my friend with ADHD, who after 5 years of psychotherapy and little progress, finally learned about ADHD and demanded a stimulant trial: "Okay, but we have to talk about something else interesting on your visits now, like good books or movies."

At the APA, too, I saw what seemed to be a lot of psychiatrists "self-medicating" with the intellectually stimulating stories of personality disorders.

It seems any physician's goal should ultimately be serving the patient's needs and not the physician's intellectual ones. There's always book clubs and other pursuits for that.

Anyway, you keep pointing out how the managed care companies have destroyed psychiatry if I understand you correctly. I am curious, is it any better in Canada where they have a single payer system? I sensed that people are drugged too much there also but I could be wrong.